Car Insurance Form

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Strathclyde Police Federation

Car Insurance Quotation Form
IMPORTANT: A specimen policy is available on request.
For your protect telephone calls may be recorded, and may be monitored.
The purpose of this form is to enable us to contact you. It does not form any part of your insurance contract.

To obtain a guaranteed quotation we will need to ask you some standard questions which we normally ask all our customers.
PROPOSER
Title:	First Name:	Surname:


Occupation (including part-time) :
Please state the serving police officer's Force:
Please enter the serving police officer's register / payroll number:

Date Of Birth (dd/mm/yyyy):


Home Address:
		Telephone (Home):
		Telephone( Work):
		Telephone (Mobile):



Post Code:		Permanent UK resident: Yes No

e-mail address:

What time of day would you like us to contact you:
Morning (9.00am - 12.00 noon) or Afternoon (1.00pm - 5.00pm)

What is your current renewal date (dd/mm/yyyy):

Please state your Current Insurer:
Current No Claims Bonus: Years		Licence Held: years months

Passed Initial Driving Course: Yes No		Passed Advanced Driving Course Yes No

ELIGIBILITY
When we provide you with a illustration quote we will assume that the following is true;
All drivers are aged between 17 and 73 and have a full EU or UK driving licence All drivers aged between 17 - 20 (inclusive) have obtained Pass Plus All drivers aged between 21 - 24 (inclusive) have a no claims discount of 2 or more years You or your partner are the main user All drivers are accident, loss and claim free for the last 5 years All drivers are conviction/fixed penalty free for the last 5 years and have no prosecution pending You or your partner are the owner and registered keeper of the car You or any driver have not been advised by a doctor to cease driving. If medical condition has been referred to the DVLA they have to confirm the licence may be kept You have not been refused renewal or motor insurance, or had a policy cancelled or voided You have not been convicted of, or received an Official Police Caution, or have any outstanding prosecutions, for any offence in connection with fraud or dishonesty of any kind The car has not been modified to increase the performance
In some circumstances you may still qualify for car insurance, please complete your details and we will telephone you to discuss your requirements.
GENERAL QUESTIONS
Car Details
Make*:		Reg. Number:
Model*:		Purchase Date (dd/mm/yyyy):
Type*:		Value: £
Engine Size (cc)*:		Annual Mileage:
* If uncertain, see description on DVLA vehicle reg. certificate		Year First Registered (yyyy):
Colour:		Vehicle's Registered Owner:

Where is the car kept overnight:		No of Cars in Family:

Use
Social Domestic and Pleasure:
or
Social Domestic and Pleasure including travel to and from work:
or
Personal business use?

Other Drivers
Title:	First Name:	Surname:

Date Of Birth (dd/mm/yyyy):		Relationship:
Licence Held: years months		Occupation:

Title:	First Name:	Surname:

Date Of Birth (dd/mm/yyyy):		Relationship:
Licence Held: years months		Occupation:

Optional Extras
Uninsured Loss Recovery? Yes No
If you have an accident where you are not at fault. ULR will will act on your behalf to recover uninsured losses e.g. your excess

Do you wish NCD Protection: Yes No

Click Submit to e-mail the information to us, or Reset to clear the form.